Provider Demographics
NPI: | 1164770319 |
---|---|
Name: | DEPARTMENT OF VETERANS AFFAIRS |
Entity Type: | Organization |
Organization Name: | DEPARTMENT OF VETERANS AFFAIRS |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | AUDIOLOGIST |
Authorized Official - Prefix: | |
Authorized Official - First Name: | AMY |
Authorized Official - Middle Name: | COMERFORD |
Authorized Official - Last Name: | NICHOLS |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | AUD, PHD |
Authorized Official - Phone: | 850-912-2233 |
Mailing Address - Street 1: | 790 VETERANS WAY |
Mailing Address - Street 2: | |
Mailing Address - City: | PENSACOLA |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 32507-1000 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 850-912-2233 |
Mailing Address - Fax: | 850-912-2461 |
Practice Address - Street 1: | 790 VETERANS WAY |
Practice Address - Street 2: | |
Practice Address - City: | PENSACOLA |
Practice Address - State: | FL |
Practice Address - Zip Code: | 32507-1000 |
Practice Address - Country: | US |
Practice Address - Phone: | 850-912-2233 |
Practice Address - Fax: | 850-912-2461 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2012-08-20 |
Last Update Date: | 2012-08-20 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
AL | 1046A | 261QV0200X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 261QV0200X | Ambulatory Health Care Facilities | Clinic/Center | VA |